﻿<!DOCTYPE html>

<html lang="en" xmlns="http://www.w3.org/1999/xhtml">

<head>
    <meta charset="utf-8" />
    <title></title>
    <style type="text/css">
        * {
            margin: 0;
            padding: 0;
            font-size: 14px;
        }

        .wrapBox {
            width: 95%;
            margin: 0 auto;
        }

        body {
            font-family: SimSun !important;
            padding-top: 5px;
            padding-bottom: 10px;
        }

        p {
            margin: 0px;
            line-height: 140%;
        }

        footer {
            color: #333;
            font-size: 1rem;
            margin-bottom: 1.5rem;
            margin-right: 5%;
            margin-top: 1.2rem;
            text-align: right;
        }

        table,
        td {
            border: 1px solid #444;
            border-collapse: collapse;
            /* text-align: center; */
            height: 1.8rem;
        }

        .classItem {
            overflow: hidden;
            width: 100%;
        }

        .classItem .itemLeft {
            float: left;
            width: 50%;
        }

        .classItem .itemCont {
            width: 50%;
            float: left;
            text-align: center;
        }

        .classItem .itemCont .lag {
            font-size: 18px;
            margin-bottom: 10px;
            display: block;
        }

        .classItem .itemCont strong {
            display: block;
        }

        .classItem .itemInput {
            border: 2px solid;
            background: #F1F4FF;
            height: 30px;
            line-height: 30px;
            margin-bottom: 5px;
            width: 80%;
            float: right;
        }

        .classItem .itemInput label {
            width: 130px;
            font-size: 14px;
            background: #fff;
            font-weight: bold;
            text-align: center;
            display: block;
        }

        /* .classItem .itemInput label::before {
            content: '';
            height: 0;
            width: 10px;
            height: 10px;
            border: 1px solid;
            text-align: center;
            margin: 19px 0 -17px -16px;
        }

        .classItem .itemInput.cur label::before {
            background: #444;
        } */


        table td {
            color: #000;
            font-size: 12px;
        }

        table .item2 {
            background: #B8CCE4;
            color: #000;
            font-size: 12px;
        }

        table .custStyle {
            background: #DCE6F1;
            color: #000;
            font-size: 12px;
        }

        table .mystyle {
            color: #000;
            font-size: 12px;
        }

        table .mystyle span {
            margin-left: 20px;
        }
    </style>
</head>

<body>
    <div class="wrapBox">
        <div class="classItem">
            <div style="overflow:hidden; text-align: center;">
                <img src=""
                    alt="" width="140" style="margin: 20px auto;" />
                <strong class="lag" style="display: block; margin-bottom: 10px; font-size: 18px;">AUTHORIZATION
                    AGREEMENT FOR RECURRING PAYMENT</strong>
            </div>
        </div>
        <style>
            .item {
                display: inline-block;
                width: 48%;
            }

            .spanTitle {
                font-size: 18px;
            }

            .myborder {
                background: #ccc;
                border: 1px solid #999;
                padding: 20px;
            }

            .item {
                margin-bottom: 10px;
            }

            .item .spanTitle {
                float: left;
                width: 120px;
                color: #000;
                font-weight: bold;
                font-size: 16px;
                text-align: right;
            }

            .item .spanBorder {
                border-bottom: 1px solid #000;
                width: 67%;
                margin-left: 130px;
                display: block;
                height: 22px;
            }
            .myACH {
                position: relative; padding: 10px; overflow: hidden; font-size: 16px  !important; text-align: center;
            }
            .myACH h2 {
                position: absolute; margin-top: -29px;
            }
            .myACH .itemC {
                width: 45%;
                border: 1px solid #999;
                margin: 5px;
                padding: 10px;
                display: inline-block;
                text-align: left;
            }
            .myACH .itemC h2 {
                margin-left: 10%;
            }
            .myACH .itemC div {
                margin-bottom: 10px;
            }
            .myACH .itemC .label {
                font-weight: bold;
            }
            .myACH .itemC p {
                background: #ccdd ; height: 25px; margin-top: 5px; line-height: 25px; padding-left: 5px;
            }

        </style>

        <div style="margin-bottom: 10px;"><span class="spanTitle">Payment Date (Circle One) :</span>
            <div style="display: inline-block; text-align: center; padding-left: 20px;"><input type="checkbox">10th
                <input type="checkbox">15th <input type="checkbox">20th</div>
        </div>
        <div>
            <div class="item">
                <span class="spanTitle">Order Number</span>
                <span class="spanBorder">2121331323</span>
            </div>
            <div class="item">
                <span class="spanTitle">Customer Name</span>
                <span class="spanBorder">2121331323</span>
            </div>
            <div class="item">
                <span class="spanTitle">Phone</span>
                <span class="spanBorder">2121331323</span>
            </div>
            <div class="item">
                <span class="spanTitle">Address</span>
                <span class="spanBorder">2121331323</span>
            </div>
        </div>
        <br>
        <div class="myborder">
            <p style="font-weight: bold;"><input type="checkbox"> Re-Enrollment - Exisiting Order No.</p>
            <p>I authorize COWAY USA, INC (referred to as "COWAY") to withdraw monthly payments, fees, and etc. from my
                existing ACH or Credit Card Recurring preregistered account. COWAY has my permission to save, store,
                and use this account information from the existing record enrolled under my name. By
                signing this authorization, I agree to the recurring payments agreement policies listed below.)</p>
        </div>
        <br>
        <div class="myACH" >
            <div class="itemC">
                <h2>Credit/Debit Card</h2>
                <div>
                    <span class="label">Account Holder</span>
                    <p>12345</p>
                </div>
                <div>
                    <span class="label">Bank Name</span>
                    <p>12345</p>
                </div>
                <div>
                    <span class="label">Routing Number</span>
                    <p>12345</p>
                </div>
                <div>
                    <span class="label">Account Number</span>
                    <p>12345</p>
                </div>

                <div>※ To insure accuracy, you MUST attach a VOIDED check</div>
                
            </div>
            <div class="itemC">
                
                <h2>ACH - Checking Account</h2>
                <div>
                    <input type="checkbox">Visa
                    <input type="checkbox">Master Card
                    <input type="checkbox">Discover
                </div>
                <div>
                    <span class="label">Card Holder Name</span>
                    <p>12345</p>
                </div>
                <div>
                    <span class="label">Card Number</span>
                    <p>12345</p>
                </div>
                <div style="width: 50%; display: inline-block;">
                    <span class="label">Expiration DATE</span>
                    <p>12345</p>
                </div>
                <div style="width: 40%; display: inline-block;">
                    <span class="label">CVV #</span>
                    <p>12345</p>
                </div><div>
                    <span class="label">Billing Address </span>
                    <p>12345</p>
                </div>
            </div>
        </div>
        <br>
        <div style="border: 1px solid #ccc; padding: 10px;">
            <h3 style="text-align: center; margin: 10px;font-size: 14px;">Automated Payment Agreement Policies</h3>
            <p>I hereby authorize COWAY USA, INC (referred to as "COWAY") to charge the fees associated with the
                services provided, including but not limited to
                COWAY's monthly rental fees, adjustments, and/or any additional charges associated with your Coway
                account from the indicated credit card/bank
                account provided above. If payment date is not indicated, payment will automatically be processed on the
                10th of each month by default. If the
                scheduled payment date falls on a weekend or holiday, the payment will be withdrawn on the following
                business day. I understand Coway is not
                responsible for any bank fees, credit/debit card fees, or related fees that may be incurred on my
                account. I agree that periodic charge will be applied to
                my account according to my COWAY billing cycle, and in order to cancel the recurring billing process, I
                am required to contact a month prior to the next
                billing cycle to either cancel the associated COWAY account, or arrange for an alternative method of
                payment. By enrolling in an automatic payment
                plan, I understand that COWAY will not mail me any invoices, statements, or bills. In the event of ACH
                transaction being returned by my bank for any
                reasons, I understand that COWAY may at its discretion attempt to process the charge again and agree to
                an additional $10.00 returned item fees will
                be charged per transaction. I agree that if I have any problems or questions regarding my account or any
                services provided by COWAY, I will contact
                COWAY for assistance using the contact information provided below. I acknowledge that the origination of
                ACH transactions to my account must
                comply with the provisions of U.S. law. I certify that I am an authorized user of this credit/debit card
                or bank account. By signing this authorization, I
                request and authorize my bank or credit/debit card to accept that I am legally authorized to enter into
                this recurring credit card billing agreement with
                COWAY.
                Electronic Copy; The parties to this document agree that a copy of the original signature (including an
                electronic copy) may be used for any and all
                purposes for which the original signature may have been used. The parties further waive any right to
                challenge the admissibility or authenticity of this
                document in a court of law based solely on the absence of an original signature.</p>
        </div>
        <br>
        <br>
        <br>
        <div class="item">
            <span class="spanTitle">SIGNATURE</span>
            <span class="spanBorder" style="height: 80px;">
                <img src="" alt="" width="200">
            </span>
        </div>
        <div class="item" style="position: relative;top: 40px;">
            <span class="spanTitle">DATE</span>
            <span class="spanBorder" style="height: 40px; text-align: center;">2121331323</span>
        </div>
        
        <p style="text-align: center; margin-top: 10px;">4221 WILSHIRE BLVD #210, LOS ANGELES, CA 90010</p>
        <p style="text-align: center; margin-top: 10px;">TEL: 213-386-3033, FAX: 323-549-0910 billing@coway-usa.com</p>
    </div>

</body>

</html>

<style>
    .SIGNATURE p {
        overflow: hidden;
        margin: 10px;
    }

    .SIGNATURE label {
        color: #000;
        display: inline-block;
        width: 200px;
        text-align: left;
        float: left;
        font-size: 12px;
    }
</style>